Open conversion after Nellix endovascular aneurysm sealing.

The Nellix endovascular aneurysm sealing system (Endologix, Irvine, Calif) was presented as a novel concept in the treatment of abdominal aortic aneurysm. After numerous adverse events, the device was voluntarily withdrawn from the market by the manufacturer. This video describes the technical approach of a successful explantation of the Nellix endograft in a patient who underwent endovascular aneurysm sealing for abdominal aortic aneurysm.

We report the successful explantation of the Nellix endograft (Endologix, Irvine, Calif) in a 77-year-old man who underwent endovascular aneurysm sealing (EVAS) in 2015 for an asymptomatic 58-mm abdominal aortic aneurysm. The patient's consent for publication was obtained.

Preoperative computed tomography angiography (CTA) showed a 25-mm-long aortic neck just below a right polar renal artery. The EVAS procedure was performed using two 150- × 10-mm Nellix devices with 60 mL of polymer, with an intrasac pressure of 180 mm Hg. Postoperative CTA confirmed the correct deployment of the grafts, sac exclusion, and patency of the iliac arteries. After 6 months from the EVAS procedure, the patient underwent a right to left femoral-femoral crossover bypass in an emergent setting because of an early left iliac endograft occlusion. At 3-year follow-up, CTA confirmed distal migration of both grafts and a type IA endoleak with enlargement of the abdominal aortic aneurysm to 64 mm. We planned an open conversion because of high risk of rupture.

The sac aneurysm and the left renal and common iliac arteries were exposed by a retroperitoneal approach with a left flank incision from the tip of the eleventh rib to the lateral rectus border at the paraumbilical level. The aortic clamp was placed between the renal and accessories arteries. The Nellix grafts were removed intact without any difficulty. The polymer bags appeared to have wall apposition. We confirmed thrombosis of the left module graft.

A bifurcated 16- × 9-mm Dacron graft (Gelsoft; Vascutek, Inchinnan, Scotland, United Kingdom) was anastomosed to the abdominal aorta with 3/0 polypropylene and Teflon felt to support the suture. The distal anastomosis was performed only for the right common iliac artery because of good patency of the femoral-femoral crossover bypass and an optimal peripheral runoff. The left branch of the Dacron graft was sutured. The patient did not have any complications in the postoperative course and was discharged on postoperative day 6 with regular ultrasound follow-up.

Postoperative surveillance of Nellix stent grafts is crucial because late open conversions could be necessary.